Category Archives: Clinical Commissioning

A Paperless NHS

Given the usual scant regard to the commonly accepted meaning of words that seems to be the norm in the NHS – “Paperless” is something that we now have in the majority of general practices and that many have had for some years and I’m really enthusiastic about the desire from the centre to drag the rest of the NHS into the Digital Age, but am really concerned that the initiative is being driven by a leadership who are, to be frank, clueless.

Firstly, the focus is wrong – Creating electronic records and/or removing paper, desirable as these may be, should not be the objective. The objective should to use technology to support and coordinate the processes of care so that the patient sees a integrated service that delivers greater convenience and quality.

This inevitably means more digital services, and will result in the creation of electronic records and the removal of paper from many processes, but in a way where these changes support process improvement. This is what happened in general practice – Processes were digitised one-by-one  and the data needed to support this digitisation was stored in electronic records. Over time these records became comprehensive and GP practices have become “paperlite”  this approach gave quick wins and avoided the risk of suddenly trying to go to fully electronic records. See Lessons from GP Computing

Secondly, we don’t have the infrastructure. Already nurses and junior doctors fight over ward terminals and the COWS (Computers on Wheels) for access to IT systems and when they finally rest a keyboard from colleagues typically find themselves  using obsolete hardware, operating systems and browsers accessing poorly integrated multiple  systems over inadequate networks. We need to address the infrastructure issues before we can go paperless (or lite). Every health and care professional needs their own device connected with ubiquitous LAN (WiFi) and WAN(3/4G) across the whole NHS estate and out into the community for those that work there. A paperless NHS without the infrastructure to support it will be worse than the current paper based system.

I’m all for putting pressure on NHS Trust to embrace a digital future and have some sympathy with the approach attributed to Richard Nixon: “When you have them by the short and curlies their hearts and minds will follow”. However, to secure the benefits that I believe are possible from the digitisation of the NHS we do have to win the hearts and minds of frontline staff and I don’t think this will be achieved by exhortations to do the impossible which will end up with ill-considered and poorly implement EPR systems  running on wholly inadequate infrastructure damaging morale and undermining patient care.

Creating a truly digital NHS requires careful design involving the public, patients, health and care professionals and digital engineers working together to create digital services to deliver truly holistic care. It requires infrastructure that is fit for purpose and needs the support of a health IT ecosystem that ensures all of the components play nicely together. See the HANDI Vision and the work of OpenGPSoC for more about what this ecosystem might look like.

I’m a firm believer that it is only by using information and information systems in innovative ways, both to support the way we directly deliver services and through analytics to effectively target and evaluate what we do, that we can hope to meet the challenges that the NHS and healthcare systems across the globe face. Headline political targets like  “a Paperless NHS” have their place in stimulating debate, but unless they are followed by meaningful action from those who have sound insight in to how digitisation might transform the way we deliver care and involve the public and patients in the process are little more than an distraction.

The Commissioning Board should focus on the Commissioning of care (both directly and through CCGs) and making sure that personal and organisational incentives for all the actors in the system are aligned with the imperative to deliver better quality more convenient services for less. They also need to ensure that the information flows required to support individual care and monitor the performance of the system as a whole are available by making these the basis on which providers are paid for their services. I can’t see how providers can achieve the transformation required without embracing IT, widespread digitisation and social media, but hold them to account for their outputs, not how they achieve them.  By setting ill-consider targets about a paperless NHS and EPRs the Commissioning Board is just giving providers excuses to fail at their core task.

Theses issues were discussed on the  #CCIO tweetchat on Wed 20 Feb  7-8pm  For the best bits and full transcript can be found here 

There are also themes here to pick up at the PHCSG UnConference on 6th June

Secondary Uses of Data – A Poachers Tale

Early in my career in health informatics I had plans to make myself fabulously rich by selling pseudonymised patient data from GP for a range of secondary purposes. I managed to spend £15 million of my backers money giving away 1000 GP systems and established a database of 6 million patients records it all ended in tears (at least from the financial perspective) in 1992.

In those early days I had a naïve view of the extent to which pseudonymisation could protect patient privacy and the ease with which data could be used for secondary purposes, so in this world I am very much a poacher turned gamekeeper, but one that still believes in the massive benefits that could flow from intelligent secondary use of patient data.

In this blog piece I won’t dwell on issues of patient privacy, suffice it to say for now, that I don’t now believe that pseudonymisation of rich datasets is fully effective but I do believe that with a sophisticated approach that we can adequately protect patient privacy when we use their data for secondary purposes. What I want to concentrate on here are the challenges of using data for secondary purposes that have nothing to do with the need to protect patient privacy.

There are two ways in which we might consider the use of data secondary, the first is that the use is not directly connected with the care of the individual patient whose data it is and the second is that it’s a use not of direct concern to the person collecting the data. Here I want to concentrate on the second definition uses with which the collector of the data is not concerned and indeed may even be ignorant of. (There are clearly some secondary uses in the sense of the first definition with which the data collector is very concerned – maybe their own research interest.)

There are a number of issues that need to be considered when using data for secondary purposes.

• What were the primary purposes for which the data were collected and how do the requirements of these primary purposes fit with the proposed secondary uses?

• Is there a conflict as to how something is best recorded for the secondary purposes? The requirements of the primary use should and will prevail

• How aware is the data recorder of the secondary purpose?. Awareness may encourage the recorder to take more care that the data is fit for the secondary purpose or may result in a range of gaming activities when they have motivation to “spin” the results of the secondary use either to their own benefit or that of the patient. E.g. blood pressure readings clustering just below the QoF cut of point.

• How important is accuracy in the recording of data to the recorder? A particular issue where users are forced to record data by system design or management pressure. If you have to record something but the accuracy of record has no direct impact on you then you may guess or make-up data or just type any old rubbish to get past a mandatory field for which you don’t have valid data. E.g. A GP recording prescribing details will take great care to record the information accurately as this will be use to produce the prescription and errors would create a serious patient risk, whereas they might be tempted to just guess to complete a mandatory dataset where they don’t see value in recording the data.

• Are definitions shared between the primary and secondary purpose and between different recorders, have they even been told what assumptions about definitions have been made? Researchers are typically much tighter that frontline data recorders e.g. some clinicians will record a diagnoses of “asthma” on the basis of limited clinical findings, just because it is probably right while others will want further confirmation and just record it as “wheezing”.

• System design and configuration can have a profound effect on what and how people record data and the extent to which they code data. Most work using data from multiple GP systems assumes data across different systems are directly compatible when the evidence suggests this is often not the case – Work by Professor Simon de Lusignan based on video observation of many consultations shows a four fold difference between the major systems in the number of consultations with no coded data and a two-fold difference in the average number of codes used http://bit.ly/kO5tgw . He also found that the way different systems mange pickings list had a significant effect on the data entered http://1.usa.gov/itbtc5 Secondary uses have to take account of system biases.

This bring us to Van de Lei’s law, coined by the eponymous Dutch health informatician “Data should not be used other than for the purposes for which it was collected” While I would not take this extreme position (and I suspect Van de Lei said it to emphasise the point, rather that to be taken literally) There are significant challenges in using data where the use is not one that was in the mind of the recorder when they recorded it.

There is a massive growth of interest in health analytics based on data extracted from GP systems. Data quality is adequate for many of these purposes but not as good or consistent as some secondary users seem to assume. While there can be dangers in telling recorders about the secondary uses to which the data they enter will be put in most cases these are greatly outweighed by the benefits of making recorders aware of secondary uses and trying to secure their cooperation to make sure what they enter is fit for the secondary uses to which it will be put.

Users of data for secondary purpose beware.

Everything you wanted to know about GP Consortia IT

I organised what I think was the first national GP computing exhibition in 1981 for the GP Computer Suppliers Association  (now part of Intellect) it was a sell out and I have been trying to organise another sell out event  without success ever since. However, with the BCS Primary Health Info Conference I am helping to organise at present I think I might have finally achieved my ambition www.primaryhealthinfo.org

This is particularly satisfying as it was the PHCSG that picked up the original GPCSA exhibition and merged it with their conference to create a series of conferences over the past 30 years of  which Primary Health Info is the most recent incarnation.

PHCSG conferences have a history of responding to the current zeitgeist in primary care IT and this year’s event looks like it will do it again this time around GP Consortia.

It is wildly recognised that better use of information and information and communications technology is going to be central if we are to rise to the challenges facing the NHS (and indeed health care systems across the developed world). In particular making the Governments plans, centred around GP Consortia, work against the background of austerity and deficit reduction is going to require the innovative use of information and IT without the luxury of being able to invest more than a modest amount in new infrastructure and systems.

The process is a bit like this.

Coming to Primary Health Info is sadly not going to answer all of your questions but it will enable you to answer many of them and help you understand that for many others nobody knows the answers and indeed that we haven’t even worked out what all the questions should be yet.

However, Primary Care Info looks like being the place where we might make progress. We have speakers, exhibitors and delegates who are working on the issues now, both in the ivory towers of Government and Informatics, but also at the grass roots with the PBI in general practice. Some of these know some answers, some think they do, while others don’t have a clue and may or may not be honest enough to admit it. There are going to be lots of opportunities to ask questions and network and greater apparent clarity may emerge in the conference bar (although experience tells me that we may not remember of brilliant late night insights in the morning).

We are also trying an experiment and running a technical steam alongside the main conference stream. This stream has speakers who are experts in the important but arcane aspects of health informatics SNOMED, HL7, CDA, XDS, FAD, PETs. This stream is intended to attract a different set of delegates mainly from the vendor community who have to know not just what these abbreviations stand for (a beer on me at the conference for the first 10 people to email me with the correct meaning of all of the above) but how to make them work in practice. We are doing this partly to attract more delegates but also to encourage a dialogue between the techies, the policy people and frontline NHS people as we believe it is only by each of these groups understanding a bit more of the others worlds that we are going to crack the challenges we face. We hope to do these through the plenary sessions, which run across both streams,  by building contacts through informal networking an by encouraging delegates to wander in to the odd session in the stream other than that which would be there natural home.

Hopefully by the end of the event we will all know a bit more, have a clearer idea of those things that still need to be resolved, made some new relationships to help us work together and probably most importantly help to influence the agenda with the powers that be.

We have a number of half-price places for those who work in the NHS and NHS GP practices, but these are going fast, so book now www.primaryhealthinfo.org

I look forward to seeing as many of you as possible at the event and would encourage you to tell your colleagues to come to, but secure your own place first.